Peer Respite Appears Effective in Lowering Inpatient, ER Use

Peer “respite”—voluntary residential programs designed to provide a safe space for individuals experiencing or at risk of experiencing a self-defined mental health crisis—may reduce the need for inpatient and emergency services for some individuals.

That’s the finding of a study by Bevin Croft, M.A., M.P.P., and Nilüfer İsvan, Ph.D., of one peer respite program known as 2nd Story in Santa Cruz County, Calif. Their findings were published March 1 in Psychiatric Services in Advance. Both authors are with the Human Services Research Institute in Cambridge, Mass.

The study found that program users were significantly less likely than nonusers to use any inpatient or emergency services after the program start date. “This analysis adds to the limited literature on service-use implications of peer respites,” they said. “Findings suggest peer respites may be an effective alternative to traditional crisis services. Peer respites may have the potential to increase meaningful choices for recovery and decrease the behavioral health system’s reliance on more coercive, less person-centered modes of service delivery.”

But an editorial accompanying the article by Croft and Laysha Ostrow, Ph.D., noted that peer respite programs differ widely and that much further research is required to determine the factors that contribute to recovery.

Croft and Isvan compared matched pairs of 139 users of 2nd Story and 139 nonusers of respite programs who had similar histories of behavioral health service use and clinical and demographic characteristics. Statistical modeling predicted the likelihood of inpatient or emergency service use after the peer respite start date and then predicted hours of inpatient and emergency service use.

2nd Story is funded by a grant from the Substance Abuse and Mental Health Services Administration that is administered through a community-based organization and overseen by the Santa Cruz County Behavioral Health Division. 2nd Story offers short-term residential support for six individuals, or “guests,” in a homelike environment for up to 14 days per visit. Some program participants return to 2nd Story after their stays to take part in program activities as visitors or volunteers.

Croft and Isvan found that after controlling for relevant covariates, the odds of using any inpatient or emergency services after the program start date were approximately 70 percent lower among respite users than nonrespite users. And among individuals who used inpatient or emergency services, a longer stay in respite was associated with fewer hours of inpatient and emergency service use.

“[E]ven with a relatively small sample, we detected a significant association between participation in a peer respite and use of inpatient and emergency services,” the authors stated.

Interestingly, however, use of the peer respite program had diminishing effects. “When the analysis was restricted to individuals who used any inpatient or emergency services, results suggested that program benefits were larger for guests who stayed no more than nine to 10 days compared with those who stayed longer,” Croft and Isvan said. “It is possible that individuals who stayed at 2nd Story longer than nine days had some shared functional or clinical characteristics that increased the need for inpatient and emergency services, regardless of respite use. One such factor may be housing instability.”

The researchers added that the relationship between length of stay and use of inpatient and emergency services could also reflect a habitual reliance on institutional services by some individuals. “In addition, the relationship may be mediated by other unobserved factors, such as health and wellness, nonclinical supports, and other life stressors,” they said.

But Croft and Isvan also stressed the dearth of research on peer respite and noted that with 16 peer respites operating nationwide and four more being planned, “the growth of peer respites outpaces any evidence of their effectiveness.”

Croft and Ostrow, in the accompanying editorial, noted that organizational features have critical implications for financing and sustainability, and careful consideration is needed to align financing with program mission. “Organizational structures range from fully peer run and autonomous to peer operated and embedded within the traditional mental health system,” they said. “Because traditional mental health treatment has a hierarchical treatment and billing structure, peer respites must purposefully interact with the rest of the mental health system. Psychiatrists who provide consultation for respites should be selected carefully for commitment to recovery principles and offered training in shared and supported decision making. Peer respites need to have a clear protocol for outreach and education activities to increase program access. This includes establishing guidelines with traditional providers regarding whether and how they provide outreach to potential guests through formal referrals and through raising community awareness.”

“Future research should continue this line of inquiry by using more rigorous experimental designs, analyzing cost implications, and incorporating additional covariates, such as quality of life, social supports, and life stressors,” the researchers said. “The observed reductions in use of inpatient and emergency services by respite guests likely translated to some degree of cost savings, given the resource-intensive nature of these services.” ■